Kevin: Evidence-based Medicine and Evidence Essay

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Quality in Health Care 1998;7:149–158

149

Enabling the implementation of evidence based practice: a conceptual framework
Alison Kitson, Gill Harvey, Brendan McCormack

Abstract
The argument put forward in this paper is that successful implementation of research into practice is a function of the interplay of three core elements—the level and nature of the evidence, the context or environment into which the research is to be placed, and the method or way in which the process is facilitated. It also proposes that because current research is inconclusive as to which of these elements is most important in successful implementation they all should have equal standing. This is contrary to the often implicit assumptions currently being generated within the clinical eVectiveness agenda where the level and rigour of the evidence seems to be the most important factor for consideration. The paper oVers a conceptual framework that considers this imbalance, showing how it might work in clarifying some of the theoretical positions and as a checklist for staV to assess what they need to do to successfully implement research into practice.
(Quality in Health Care 1998;7:149–158)
Keywords: implementing research into practice; clinical eVectiveness; evidence-based practice; facilitation; change management

Introduction
Despite growing acknowledgement within the research community that the implementation of research into practice is a complex and messy task, conceptual models describing the
Royal College of
Nursing Institute,
Royal College of
Nursing, London, UK
Alison Kitson, professor and director
Royal College of
Nursing Institute,
RadcliVe Infirmary,
Woodstock Road,
Oxford, UK
Gill Harvey, head of quality improvement
RCNI
Brendan McCormack, head of practice development, co-director gerontological nursing
Correspondence to:
Professor Alison Kitson,
Royal College of Nursing
Institute, Royal College of
Nursing, 20 Cavendish
Square, London W1M 0AB,
UK.

process still tend to be unidimensional, suggesting some linearity and logic. For example,
Lomas1 cites the model developed in the
Milbank Quarterly2 as an acceptable representation or mapping of issues, contexts, and processes suggesting that the complexities in implementation occur when evidence meets everyday practice (fig 1), while Haines and
Jones3 suggest a more straightforward connection between continuing education, audit, and research findings (fig 2). Indeed, the most recent guidance from the Department of
Health in England4 on clinical eVectiveness, suggests a framework based on informing, monitoring, and changing practice. Although such frameworks have superficial appeal, if applied literally, they often fail to help those involved in change processes to capture their complexity, thereby reducing the potential for successful implementation.5–8
Given the apparent lack of success of these approaches, it is important to continue to look for other ways of representing the complexity of the process of change and implementation of research findings. To this end, a research and development team in the Royal College of
Nursing (RCN) Institute has been working on the development of a conceptual framework which represents the interplay and interdependence of many factors influencing the eVective uptake of research evidence into practice. Representation of the elements in the framework may be used to help clinicians to think about their implementation strategies.
The framework might also be used to generate

Research information
Synthesis
Distillation
Appraisal
Credible dissemination
Awareness
Attitude
Knowledge
External factors for example new information

Overall practice environment
Educational
environment

Administrative environment Regulation

Information

Incentives

Practitioner…